Routine inspection·June 10, 2022

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with staff, Reinalyn Martin, who assisted with the visit. LPA spoke with Administrator, Silvia Castro over the phone and explained the purpose of today's visit. Administrator joined the visit at around 4:30pm. Facility is licensed to serve six (6) non-ambulatory residents, age 60 and above, of which one (1) maybe bedridden. Annual licensing fee is current. Administrator certificate is current and the expiration date is 10/14/22. Facility has hospice waiver for two (2). Currently, four (4) hospice residents residing at the facility. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is a single story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility consisted of 4 residents bedroom, 2 1/2 bathrooms, dining room, kitchen, TV/living room, and family room. Facility has a main entry point for screening. All four residents bedrooms were toured. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 112.1 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene s upplies was observed. No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. ( - continued in LIC 809 C-) Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. A dual device of Smoke detectors combined with carbon monoxide detectors are tested and operable. Fire extinguishers’ last service is 4/15/22 and are fully charged. The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked storage room and inaccessible to residents. Resident records are stored in a locked storage room and inaccessible to residents. Toxic substances are inaccessible to residents. Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D. An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided.